The importance of cultural competence in medicine has gained recognition in academic forums and literature over the past five decades. These discussions were born of the realities that face health care today as a necessary response to the increasingly diverse U.S. population, coupled with emerging evidence of health care disparities and the initiatives that seek to eliminate them. Surgeons and the populations they serve are equally affected by these disparities. In this article, we discuss the history and evolution of cultural competence in health care; its implications for surgeons, residents, and surgical practice; and methods that may direct surgeons in their pursuit of the skills required to serve diverse patient groups.
The role of diversity and cultural competence in the practice of surgery will continue to grow as the ethnic composition of our patient population changes. As diversity is ampliﬁed in society, it is increasingly important for surgeons to be adept at interacting with patients from all backgrounds. The concept of cultural competency centers on the understanding of the specific cultural, linguistic, social, and economic nuances of a particular group of people and their community. In health care, cultural competency is the recognition of culturally influenced health beliefs and behaviors, disease prevalence and incidence, and disparities within a specific population of patients, along with the incorporation of cultural education programs, assessment of cross-cultural care, and improvement of access to care.1
Evolution of cultural competence
The genesis of cultural competency awareness can be related to the history of the U.S. and the diversity of its population. This population has evolved significantly over the past five decades, with two critical events that have accelerated the need for cultural competence. One event is the ongoing Civil Rights Movement that began in the 1950s, in which African Americans, women, homosexual and transgender persons, individuals with disabilities, and other minority groups have alerted the country to their distinct identities and long histories of oppression; the other component is the growing number of immigrant populations within the U.S.2
The 2010 U.S. Census shows that more than 40 percent of the population are members of a minority group. In the past 10 years, every minority group gained in population at higher rates than whites. Asian and Hispanic or Latino individuals surpassed all other ethnic groups in population growth, with 43 percent increases in each population. African Americans increased by a rate of 12 percent and Native Americans by 28.4 percent. Hispanic or Latino persons now account for the largest minority group in the U.S., at 16 percent of population.3
New immigrants to this country bring with them a spectrum of unique cultural, linguistic, religious, and political backgrounds. Melding these backgrounds with the history, experiences, and expectations of U.S.–born populations creates both challenges and opportunities for health care providers.1,2 Health care providers serving these populations may be met with difficulty initially in navigating the various beliefs that influence patient decision making; however, with each challenge comes an opportunity for providers to learn from their patients and sharpen their communication skills. With this increase in a diverse U.S. population, health care systems and providers need to respond to patients’ varied perspectives, values, and behaviors regarding health and well-being. Failure to understand and manage these social and cultural differences may have significant health consequences for minority groups in particular.1
The concept of cultural competence for health care providers has emerged, in part, to address the factors that may contribute to racial/ethnic disparities in health care.4 The ultimate goal is to deliver the highest quality of care to every patient, regardless of race, ethnicity, cultural background, sexual orientation, or English proficiency.5
Barriers to culturally competent care
Barriers between patients, providers, and the U.S. health care system that may affect quality and contribute to racial/ethnic disparities in care include the following:
- Lack of diversity in health care leadership and workforce6,7
- Systems of care poorly designed to meet the needs of diverse patient populations4
- Poor communication between providers and patients of varying racial, ethnic, or socioeconomic backgrounds8,9
Cultural competence at the individual level
At the individual level, a physician may harbor prejudices including racism, sexism, homophobia, as well as various ethnic and religious biases, which may cause a great deal of personal discomfort, particularly because discussion of these issues is often viewed as taboo. Such biases, ingrained in the physician’s subconscious, have an impact on the quality of health care provided.10
It is important to note that on the individual level, cultural competence requires more than practicing tolerance. It entails identifying and challenging one’s own cultural assumptions, values, and beliefs, in addition to the development of empathy—the ability to see the world through another’s eyes, or at the very least, the ability to recognize that patients from various ethnic backgrounds may view the world through a different cultural lens.3 The movement toward cultural competency involves diminishing ethnocentric attitudes and developing greater flexibility and non-judgmental perceptions.11
Cultural competence at the institutional level
At the institutional level, organizational factors, policies, and culture can also affect the quality of care provided. A total of five essential behaviors contribute to a system or institution’s ability to become more culturally competent:7,12
- Valuing diversity
- Having the capacity for cultural self-assessment
- Being conscious of the dynamics inherent when cultures interact
- Having institutionalized cultural knowledge
- Developing adaptations to service delivery reflecting an understanding of cultural diversity
These five behaviors should be manifested at every level of an organization.
Cultural competence and surgeons
The Institute of Medicine’s (IOM) report, titled Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, has promoted awareness of health care disparities around the world and has served as a catalyst for positive change.4 The IOM report found considerable evidence that racial and ethnic minorities in the U.S. receive lower quality of health services and have worse health status indicators than do Caucasian Americans. Furthermore, the report asserts that racial differences in health outcome exist even when insurance status, income, age, and severity of conditions are comparable. The report suggests that these disparities are caused, in part, by conscious and unconscious bias on the part of the caregiver.4 Like all health care practitioners, the shifting ethnic and cultural demographics of the U.S. population pose a challenge for surgeons, as they must navigate varying cultural traditions and values to evaluate and connect with patients in order to deliver effective care.
The rapid pace of surgical practice can present a formidable challenge in establishing trust and confidence between surgeon and patient. Active patient–provider participation is required preoperatively in order to optimize outcomes. Culture, education, and belief systems have a tremendous influence on all aspects of the surgical experience, from accepting surgery as a treatment option, to pain management and performance of postoperative care.
Communication and informed consent
In order for a patient to make a truly informed decision, the surgeon must go beyond offering a simple explanation of proposed diagnostic and treatment plans; they must attempt to elicit reasons for apprehension or refusal of treatment, as there may be underlying cultural beliefs, fears, or myths that present obstacles to care. It is crucial that communication barriers are acknowledged and appropriately managed during patient encounters. Moreover, informed consent requires that surgeons communicate effectively to patients the risks, benefits, and alternatives to surgery, and ensure that the patients are willing to participate in follow-up and appropriate postoperative care. Proper communication needs to be determined on a case-by-case basis, and the physician should rely on cultural competence, sensitivity, and a clear set of informational and trust-building goals when dispensing this information to patients. Communication barriers—whether derived from cultural or social origins—can have a significantly negative impact on patient satisfaction, compliance, clinical outcomes, and even malpractice suits.11,12
Health disparities and outcomes
Disparities in the delivery of health care and clinical outcomes are widely recognized, with minority and low-income populations adversely affected.4 The Centers for Disease Control and Prevention’s Healthy People 2020 initiative acknowledges this inequality and identifies the reduction of health disparities as a primary objective.13 Beyond race, socioeconomic status has received considerable attention as another contributor to disparities in clinical outcomes.14,15 Evidence suggests institutional complicity is also a culprit, in that hospitals where minority patients receive treatment have significantly poorer outcomes overall due to lack of resources.16,17 Other research suggests that behavioral issues, including provider bias and patient attitudes, negatively influence patient-provider communication and are possible explanations for the outcomes seen in minority patients.4
Disparities in surgical care are most commonly seen in cancer and trauma care for the underinsured, the uninsured, and ethnic minorities.18-20 Race and insurance status have consistently been shown as predictors of mortality after trauma.14,21 In addition, racial differences have also been seen in ambulatory surgery outcomes.22 Despite controlling for health insurance, disparities continue to exist in surgical outcomes among patients with lower socioeconomic status.23,24 Ultimately, the surgical workforce needs to be trained to recognize and address the distinct social and cultural values of patients in order to eliminate disparities in surgical care.
A growing number of residents and surgeons are crossing international borders with the intention of reducing disparities between global wealth and poverty. However, American surgeons have been relative latecomers to international volunteerism.25 U.S. physicians recognize their obligation to be leaders in providing relief to the global burden of surgical disease. Increasingly, surgical residents have displayed interest in participating in global health and volunteerism. A national survey of Resident Members of the American College of Surgeons revealed that 92 percent were interested in an international elective, and 85 percent planned to volunteer in practice.26 Another survey showed that 57 percent of surgical programs that were not currently offering global surgery electives had program leaders who were interested in initiating them.4 The growing demand for international surgical volunteerism within surgical residencies underscores the importance of developing a methodical training curriculum focused on providing care to culturally and socially distinct populations.27 Developing tools and honing skills in cultural competency within our own diverse population allows surgeons to become more attuned to these differences, serving as preparation for an experience abroad. Volunteerism is one way surgeons can seek and develop strategies that may potentially reduce barriers to obtaining health care and decrease health disparities in the long-term in both urban and rural underserved regions within the U.S.
The American surgical workforce is lacking in representation by minorities and women. The realities of medical school enrollment portend the changing gender balance in the surgical workforce—but less so for ethnic minorities. This is attributable to pipeline limitations, as medical schools have had only minimal increases in minority enrollment.28,29 U.S. medical schools have responded to these deficiencies by incorporating courses that address communications skills and cultural competence training into their curriculum.30,31 In 2001, the Accreditation Council for Graduate Medical Education made cross-cultural education a requirement for both medical students and residents.32
Cultural competence training
There are several different approaches to cultural competence training, and various learning tools are, in fact, available for physicians, but none are tailored specifically to surgeons. Traditional approaches focus on cultural sensitivity, cultural adaptability, and cross-cultural skills.6
Cultural sensitivity focuses on health care provider attitudes as well as various qualities that are indicative of professionalism. This approach emphasizes the fact that cultural competence is achieved when the pillars of professionalism are met: empathy, humility, respect, and sensitivity.33,34 Cultural adaptability emphasizes the importance of acquiring general knowledge of health attitudes and behaviors specific to a certain race or ethnic group. Providers who work with a particular patient population may benefit from this knowledge-based approach. Information regarding the customs, beliefs, history, sociopolitical, and economic factors that shape the community are crucial in this dynamic.35 And lastly, cross-cultural skills acquisition—in which patient-provider communication is strengthened by focusing on the social, cultural, and health issues of varying population groups while emphasizing professionalism—is vital.36,37 The health care provider allows the patient to communicate the cultural beliefs that influence their health beliefs, attitudes, and decision-making processes. Ideally, a curriculum that integrates these different approaches equips surgeons with the skills required to serve diverse populations.
There are numerous tools available for physicians and other health care providers through the U.S. Department of Health and Human Services’ Health Resources and Services Administration to elevate our own cultural beliefs to consciousness and help clarify the various cultural views of our progressively diverse patient population.38 These tools include self-assessment modules, cultural competency curriculum, training modules, and resources designed to identify and improve deficiencies in culturally competent care.
Health care disparities are a critical issue in the U.S. Cultural competency is a necessary and critical component in solving the problem. Culturally competent care education (CCCE) must be well-developed and formally integrated into medical education and surgical practice to ensure that patients are treated in a professional manner. The development of effective CCCE programs targeted at surgeons is challenging and requires immediate attention, particularly from the surgical academic community and the American College of Surgeons.
Health care policy, social justice, cultural sensitivity, and cultural competency are all challenges in the field of health care for the diverse populations we serve.31 These challenges notwithstanding, the delivery of culturally competent surgical care will become the hallmark of surgical professionalism both perceived and real as we continue to strive to provide quality care for our surgical patients.
- Betancourt JR, Green AR, Carrillo JE, Ananeh-Firempong O. Defining cultural competence: A practical framework for addressing racial/ethnic disparities in health and healthcare. Public Health Rep. 2003;118(4):293-302.
- Chin JL. Culturally competent health care. Public Health Rep. 2000;115(1):25-33.
- U.S. Census Bureau 2010. Available at: www.census.gov/2010census/. Accessed August 16, 2011.
- National Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academic Press; 2003.
- U.S. Department of Health and Human Services. Office of Minority Health National Standards for Culturally and Linguistically Appropriate Services in Health Care. Final Report. Available at http://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf. Accessed January 10, 2012.
- Butler PD, Longaker MT, Britt LD. Major deficit in the number of underrepresented minority academic surgeons persist. Ann Surg. 2008;248(5):704-711.
- Dill MJ, Poll-Hunter NI. Increasing workforce diversity. Acad Med. 2010;5(1):179.
- Stewart M, Brown JB, Boon H, Evidence on patient-doctor communication. Cancer Prev Control. 1999;3(1):25-30.
- Cooper-Patrick L, Gallo JJ, Gonzalez JJ, Vu HT, Powe NR, Nelson C, Ford DE. Race, gender and partnership in the patient-physician relationship. JAMA.1999;282(6):583-589.
- Eisenberg JM. Social influences on medical decision making by clinicians. Ann Intern Med. 1979;90(6):957-964.
- American Occupational Therapy Association Inc. Cultural Competency for Health Professionals. Maryland: 2000.
- National Centre for Cultural Competence. Conceptual Frameworks/Models, Guiding Values and Principles. Washington DC: Georgetown University Child Development Centre; 2006.
- Centers for Disease Control and Prevention. Office of Minority Health and Health Disparities. Eliminating Racial and Ethnic Health Disparities. Available at: www.cdc.gov/omhd/About/disparities.htm. Accessed August 16, 2011.
- Rosen H, Saleh F, Lipsitz S, Rogers SO Jr, Gawande AA. Downwardly mobile: The accidental cost of being uninsured. Arch Surg. 2009;144(11):1006-1011.
- Council on Ethical and Judicial Affairs. Black-White disparities in health care. JAMA. 1990;263(17):2344-2346.
- Lucas FL, Stukel TA, Morris AM, Siewers AE, Birkmeyer JD. Race and surgical mortality in the United States. Ann Surg. 2006;243(2):281-286.
- National Institute of Medicine. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: National Academies Press; 2006.
- Haider AH, Efron DT, Haut ER, DiRusso SM, Sullivan T, Cornwell EE 3rd. Black children experience worse clinical and functional outcomes after traumatic brain injury: An analysis of the National Pediatric Trauma Registry. J Trauma. 2007;62(5):1259-1262.
- Trivers KF, Shaw KM, Sabatino SA, Shapiro JA, Coates RJ. Trends in colorectal cancer screening disparities in people aged 50-64 years, 2000-2005. Am J Prev Med. 2008;35(3):185-193.
- Alexandraki I, Mooradian AD. Barriers related to mammography use for breast cancer screening among minority women. J Natl Med Assoc. 2010;102(3):206-218.
- Haider AH, Chang DC, Efron DT, Haut ER, Crandall M, Cornwell EE. Race and insurance status as risk factors for trauma mortality. Arch Surg. 2008;143(10):945-949.
- Menachemi N, Chukmaitov A, Brown LS, Saunders C, Brooks RG. Quality of care differs by patient characteristics: Outcome disparities after ambulatory surgical procedures. Am J Med Qual. 2007;22(6):395-401.
- Bratu I, Martens PJ, Leslie WD, Dik N, Chateau K, Katz A. Pediatric appendicitis rupture rate: Disparities despite universal health care. J Pediatr Surg. 2008;43(11):1964-1969.
- White A, Vernon SW, Franzini L, Du XL. Racial and ethnic disparities in colorectal cancer screening persisted despite expansion of Medicare reimbursement. Cancer Epidemiol Biomarkers Prev. 2011;20(5):811-817.
- Farmer PE, Kim JY. Surgery and global health: A view from beyond the OR. World J Surg. 2008;35(4):533-536.
- Powell AC, Casey K, Liewehr DJ, Hayanga A, James TA, Cherr GS. Results of a national survey of surgical resident interest in international experience, electives, and volunteerism. J Am Coll Surg. 2009;208:304-312.
- Jayaraman SP, Ayzengart AL, Goetz LH, Ozgediz D, Farmer DL. Global health in general surgery residency: A national survey. J Am Coll Surg. 2009;208(3):426-433.
- Butler PD, Longaker MT, Britt LD. Major deficit in the number of underrepresented minority academic surgeons persist. Ann Surg. 2008;248(5):704-711.
- Dill MJ, Poll-Hunter NI. Increasing workforce diversity. Acad Med. 2010;85(1):179.
- Lum CK, Korenman SG. Cultural-sensitivity training in U.S. medical schools. Acad Med. 1994;69(3):239-241.
- Louden RF, Anderson PM, Gill PS, Greenfield SM. Educating medical students for work in culturally diverse societies. JAMA. 1999;282(9):875-880.
- Accreditation Council for Graduate Medical Education. ACGME outcomes project: General competencies. Available at: http://www.acgme.org/outcomes/comptv13.htm. Accessed July 27, 2011.
- Bobo L, Womeodu RJ, Knox AL Jr. Principles of intercultural medicine in an internal medicine program. Am J Med Sci. 1991;302(4):244-248.
- Gonzales-Lee T, Simon HJ. Teaching Spanish and cross-cultural sensitivity to medical students. West J Med. 1991;146(4):502-504.
- Paniagua FA. Assessing and Treating Culturally Diverse Clients: A Practical Guide. Thousand Oaks, CA: Sage Publications; 1994.
- Shapiro J, Lenahan P. Family medicine in a culturally diverse world: A solution-oriented approach to common cross-cultural problems in medical encounters. Fam Med. 1996;28(4):249-255.
- Carrillo JE, Green AR, Betancourt JR. Cross-cultural primary care: A patient-based approach. Ann Intern Med. 1999;130(10):829-834.
- U.S. Department of Health & Human Services Office of Minority Health. A Physician’s Practical Guide to Culturally Competent Care. Available at: http://www.minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=12. Accessed September 23, 2011